Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Pertrochanteric Hip Fracture Fixation with 3 Hole and 4 Hole DHS Side Plates ‑ A Retrospective Patient Record Review

Introduction: Dynamic hip screw fixation (DHS) with a 4‑hole side plate and 4 bi‑cortical screws is considered by many to be the standard implant for extracapsular hip fractures. The 4‑hole side plate, however, has several disadvantages including longer incision, increase in operating time, bleeding and increased wound morbidity. Biomechanical studies have shown that most of the force in a 4‑hole DHS fixation is borne by the proximal three screws. This study (specifically) compares the outcome of fixation using 3‑hole and 4‑hole DHS in extracapsular hip fracture fixations (with the hypothesis being that 3‑hole plate is adequate even in unstable intertrochanteric fractures. Patients and Methods: Atotal of 72 consecutive patients who had DHS fixation with either a 3 hole or 4 hole DHS side plate and who were either directly operated or supervised by a single consultant were recruited. Fractures were classified using the AO fracture classification system as stable (AO/OTA 31A1–31A2.1) and unstable (31A2.2–31A3.3 subtypes) for ease of comparison. Failure was defined as metalwork breakage, nonunion, screw cut‑out or pull out or any other complications of bone healing requiring a revision. Results: A total of 23 patients (68.1%) were female, whereas 49 patients (31.9%) were male. Fractures in 33 patients were classified as stable with the (AO/OTA 31A1–31A2.1) and unstable in 39 patients with (31A2.2–31A3.3 subtypes). Thirty‑three (45.8%) patients had fixation with 3‑hole side plate, whereas 39 (55.2%) patients had fixation with 4‑hole side plate. In the 3 hole group, 17 patients had stable fractures, whereas 16 patients had unstable fracture configuration while in the 4‑hole DHS side plate group, 16 patients had stable fracture configuration, whereas 23 patients had unstable fracture. The mean change in hemoglobin was lower for the 3‑hole DHS group (3 hole‑6.64 g/l versus 4Hole 12.41 g/l) (t = 1.732, P = 0.090, P ≤ 0.05). One patient in each group also had metalwork failure with screw cut‑out through the head and the other being (screw breakage) complete failure of the screw necessitating conversion to total hip arthroplasty. Conclusion: Three‑hole DHS plate offers comparable outcome with its 4‑hole counterpart even with unstable intertrochanteric fractures, with slightly less blood loss and smaller scars

Analysis of complications associated with combined single stage anterior and posterior cervical spine decompression fusion surgery

Introduction There is no consensus regarding anterior or posterior cervical spine approach for pathologies in the cervical spine. Combined anterior and posterior cervical spine surgery, even though negates the disadvantages of a single approach, is however fraught with challenges. The aim of the study is to analyse the complications of single stage combined anterior and posterior cervical spine decompression and instrumented fusion (SSAPCDF). Method This is a retrospective study of 44 patients (31 male and 13 females) who underwent SSAPCDF between 2013 - 2023. The indications for surgery were degenerative in 72% of patients, tumour in 15%, trauma in 9 % and infection in 2%. The complications were divided in to intraoperative and postoperative. The return to theatre within 30 days, within 90 days and within 365 days were noted. Different parameters were noted including planned and unplanned HDU and ITU admissions, and re-admission to the hospital. Results There were no intraoperative complications. Post-operatively, 9% of patients had wound healing complications. Two of the tumour patients had post-operative airway complications with stridor present. Return to theatre was 9% within 30 days, two were for wound washout and two for tracheostomy, this reduced to 2% within 90 days which was one patient for wound washout and closure of cervico-thoracic spine with MSCC. There was no return to theatre between 90 and 365 days. Two tumour patients had unplanned HDU and ITU admissions post-operatively, while one degenerative and one infection patient had planned ITU admissions. There is no association between indication and readmission to the hospital between 31 – 90 days or between 91 – 365 days. Conclusion SSAPCDF is found to be quite safe with the correct level of expertise and does not increase the risk beyond that of a normal anterior or posterior cervical spine surgery